HomeMy WebLinkAboutMarkiewicz ,,1® � �
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. ./ Town Hall, 53095 Main Road
,, P.O. Box 1179
® �� i'� Southold, New York 11971
7UDITH T.TERRY •�„ir/ o'� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1195-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MARKIEWICZ, ALFRED
Mailing Address 1 490 VICTORIA DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 490 VICTORIA DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1137
Tax Map No. section 78.00 block 9 lot 71 .003
Cross Street COLUMBIA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/31/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ',\\FFOur
"'�'
Town of Southold � _ ' = Application No. 11 9 ,T
Judith T. Terry, Town Clerk � $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 v' i
ti $25.00 - Non-Residential
Southold, New York 11971 O ® `,
Telephone( 1.a� 'te
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- - for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: AI F4'fc� 7-e 1t//
OWNER MAILING ADDRESS: 4(91, I/(c,tarn Ds ,
OWNER PROPERTY ADDRESS: (�77ryn
OWNER TELEPHONE NUMBER: 6 5- - /13
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TAX MAP NO. : Section / Block Lot 9 / , 3
CROSS STREET: Lam//
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existin
Residenti.. Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
/ S'gnatu e of Applicant
RECEIVED BY:
gown Clerk's Office
DATE: � lL� 1P �
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